Approach Considerations

A mid-midline incision is best suited for enteroenterostomy. Enteroenterostomy as a part of gastric bypass surgery can also be performed laparoscopically with sutures or staplers. Enteroenterostomy can be done either in a single layer or in two layers; no significant difference has been found between the two approaches.

Enteroenterostomy may take the following three forms:

End-to-end - The advantage with an end-to-end enterostomy is that there is only one suture line, in contrast to the two suture lines in an end-to-side anastomosis and the three suture lines in a side-to-side anastomosis; the disadvantage is that there is a luminal size disparity between the proximal dilated bowel and the distal collapsed bowel that may be difficult to manage, and the critical mesenteric angle is more prone to anastomotic leakage

End-to-side

Side-to-side (ie, lateral) - This is used for bypass (short-circuit operation) but can be also be used after resection; the advantages are that the luminal size disparity is not a problem and that a large stoma can be created; a disadvantage is that the loop is blind

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Creation of Enteroenterostomy

Hand-sewn vs stapled anastomosis

Anastomosis can be hand-sewn or stapled (a stapled anastomosis is quicker and ensures inversion of mucosa); no significant difference has been found between the two. A stapled anastomosis is usually performed in a side-to-side fashion by using a linear cutter or GIA stapler; it may also be done in an end-to-side manner. An end-to-end stapled anastomosis can be performed as well (the circumference is divided into three equal segments, each of which is closed with a linear stapler or a TA stapler).

Suture type

Interrupted or continuous sutures may be used for enteroenterostomy. Because interrupted sutures cause less ischemia and ensure better adjustment of luminal discrepancy but take more time, it is important to use more suture material and more knots and ensure that suture material is left in situ. Continuous over-and-over (running) suture is hemostatic, takes less time, uses less suture material, requires fewer knots, and leaves suture material in situ. However, this approach leads to more ischemia.

Single-layer vs two-layer anastomosis

For a single-layer (seromusculo-submucosal, extramucosal) anastomosis, bites include all layers except mucosa (submucosa must be included). The advantages include less ischemia and less compromise (narrowing) of the lumen.

Subsequently, the surgeon should anterior inner all layers (Connell–full thickness, inverting, outside in and then inside out on the same bowel end with loop on mucosa) or through and through continuous. The serosa is lifted with fine nontoothed forceps so that mucosa falls back while the mucosa is being inverted by the assistant with a fine nontoothed forceps and then place anterior outer seromuscular (Lembert) sutures (usually interrupted).

Another option is to start in the middle of the posterior layer with a double-needled suture; one half of the posterior layer is completed with one needle and the other half with the other needle. The suture then turns around both corners and continues in both halves of the anterior layer and meets in the middle of the anterior layer. Any gaps or bleeding points require additional interrupted sutures in between.

The mesenteric gap is then closed; bites include the peritoneum only and should avoid mesenteric vessels.

End-to-end anastomosis

Noncrushing soft intestinal clamps (preferably linen-shod) are used on the two divided ends to bring them together, to prevent spill of intestinal contents, and to provide temporary hemostasis from the cut bowel ends. However, they should not include and occlude the vessels in the mesentery. Thereafter, stay sutures are taken at two (mesenteric and antimesenteric) corners, and the mesenteric angle of sorrow (bare area between two layers of mesentery) is closed with a horizontal U (box) stitch.

Luminal disparity

Disparities in luminal diameter or circumference between the proximal dilated bowel and the distal collapsed bowel can be handled in several ways, as follows:

Interrupted sutures dividing each wall (posterior and anterior) into halves and then each half into further halves

In a continuous suture, the distance between two consecutive bites should be smaller on the narrower lumen side and greater on the wider lumen side

Cheatle maneuver - Longitudinal incision along the antimesenteric border on the narrow lumen to increase its circumference

End (narrow) to side (wide) anastomosis - The end of the wide side is closed with sutures or staples

Side-to-side anastomosis

Side-to-side anastomosis

Side-to-side anastomosis is done on the antimesenteric borders of the two loops; it avoids the mesentery and thus does not interfere with the blood supply. Noncrushing soft intestinal clamps are used on the two divided ends. It is usually done as a two-layer anastomosis. Stay sutures are taken at two corners. Posterior outer seromuscular (Lembert) sutures (usually interrupted) are taken. The lumen should be opened about 5 mm from the seromuscular layer; this opening should be as close to the closed ends as possible to avoid significant blind loop. Cautery can be used for opening the bowel (coagulating current for muscle and cutting for mucosa); contents are sucked and mopped.

The surgeon should posterior inner all layers (full thickness) through and through (over and over) continuous (for better hemostasis) with intermittent (after every 4-5 bites) locking to avoid a pursestring effect. Anterior inner all layers (Connell–full thickness, inverting, outside in and then inside out on the same bowel end with loop on mucosa) or through and through continuous; the serosa is lifted with fine nontoothed forceps so that mucosa falls back while the mucosa is being inverted by the assistant with a fine nontoothed forceps. The surgeon should anterior outer seromuscular (Lembert) sutures (usually interrupted). Note that a drain is not required for enteroenterostomy.